Patient Centered Care

I hope you will be hearing a lot about patient centered care in the near future if you haven’t already. The term implies a newly directed focus on what is best for patients amidst a huge, complicated and cumbersome health care system that has become distracted from its primary purpose.

Interestingly, this is where we started in the medical profession during the Hippocratic era – with the focus of health care firmly on the patient. It was further refined by Sir William Osler in the late 1800’s and early 1900’s. Everything that was done in medicine in those days had one purpose and that was to make patients better.

Sometime in the mid to late Twentieth Century, we seemed to have lost our focus. Technology was making huge strides. We were finding new ways to treat diseases that had been previously untreatable. Health care began to cost more. Insurance companies were there to help patients pay for the increasing costs. Doctors readily accepted this because it was a way to get paid for services without having to wait for patients to pay. Those were the golden years in health care. Research flourished. Doctors even made house calls. The health care system in the United States was the best in the world.

Economics Centered Care

Then something happened. More people were living longer. The government felt the need to protect the nonworking elderly, many of whom couldn’t afford health insurance, with government-sponsored insurance - Medicare. In order to control the cost of the program however, many regulations were put in place to prevent doctors and hospitals from charging their full fees. Doctors could elect to “opt out” and not participate in the plan, but if they did, they would lose patients to those doctors who did participate. Soon other insurance companies were doing similar things and all of a sudden, lots of doctors, especially those in primary care were struggling. In order for them to survive, they were told in the 1990’s, they would have to give up their offices and join large health care organizations. These organizations would then supposedly be able to control medical costs. The primary care physicians were therefore stripped of their autonomy and subjected to the rules of the insurance organizations, which controlled all the purse strings. Unfortunately, medical care never became any cheaper or more affordable as promised. The money just shifted into the pockets of insurance and business executives, many of whom probably thought they were attempting to improve the system but in reality were only making it worse. And besides, there was money to be made in the health care business, so why shouldn’t they profit from as much as all the other executives all over the country.

And now, sadly, primary care appears to be dying. Nobody wants to do that any more. The training is too long, the educational debt is too high, the work is too hard, and there’s not enough money in it to make it worthwhile.

Furthermore, the system itself is dying. As costs continue to rise, research is going down, quality of care is going down, access to care is at an all time low and we are rapidly developing a shortage of primary care physicians to take care of the “baby boomers” who are getting older now and becoming ill. Insurance companies never paid much for prevention, so now we have millions of diabetics and cancer victims that are using lots of resources that could have been prevented had those dollars been used for screening and prevention as the doctors wanted them used.

So now we have a society where healthcare has become anything but patient-centered.

Money is the primary focus currently and if it has its way, we will soon be overtly rationing health care. Someone (probably a clerk in an insurance office) will be directing who gets to use which resource. This is already happening covertly, although it’s not called “rationing”. It’s called “cost containment”.

Disease Centered Care

To a lesser extent, the well-intentioned evidence-based medicine movement also shifts the focus away from the patient and more toward the disease. Some would argue that the patient is the one to benefit from disease control. Truly evidence-based medicine holds an important place in medicine today as a means to an end, but it is becoming an end to the means, giving rise to a new set of regulations and “guidelines” that could well become mandates in the near future. This will further deteriorate patient care because the doctors will be focusing on making sure they have done all the HgbA1c’s, etc. that they have to do in order to get paid. Furthermore they will not be accepting sicker or poorly compliant patients into their offices (unless that is mandated also), because those patients will make their numbers look bad.

Also, we have to keep in perspective how to use the evidence we have obtained to take care of patients. A randomized, double-blinded, controlled study almost always excludes people who are not in a certain age group and who have other comorbidities other than the one being studied. After the study is completed, we get an article in a reputable medical journal that says a particular drug appears to be helpful for a certain illness in the type of patients entered into this study. It is a significant extrapolation for the media and insurance companies and the government and the rest of us to say that what worked for a particular cohort of patients in a certain age group with one particular disease without other comorbidities must be good for everybody, regardless of age, , other illnesses, other medications, other environments, etc. It is good as a guideline to have and use this information for taking care of particular patients, but it is not right to connect its use by a particular doctor in a particular area to the quality of his/her practice or his/her paycheck.

For example, if I don’t put an 88 yo hospitalized patient with congestive heart failure and 10 other illnesses on a beta-blocker and an ACE Inhibitor along with his/her 10 other medications, that chart will be audited and someone from the medical records department will be hunting me down wanting me to add some comment in the chart as to why that person is not on those medications. The focus here is obviously not on the patient but on the “guidelines”, which have gone beyond being mere guidelines, and on other concerns like “pay for performance” and meeting insurance demands in the disguised name of “quality”. I appreciate the fact that these medications may be helpful for this patient but they may also make things worse. The evidence may not hold true for this person who is a far cry from the type of patient included in the study. The attending physician may be the best person to decide whether to risk adding another medication or not.

Insurance Centered Care

Furthermore, if I keep that same patient in the hospital one extra day longer than Medicare believes it’s necessary in order to make sure the patient is stable after 5 of 10 medications have been changed, this amounts to “Medicare fraud”, for which the doctor and hospital could receive sanctions. And so hospital physicians all over the country are forced to send people like this home or to a nursing home earlier than we would like. This just results in increased post-discharge complications and frequent readmissions and overall poor quality of care, not to mention the dissatisfaction it causes among patients and physicians alike. I understand the need to contain costs for society, but the current system is very patient-unfriendly.

Other insurance organizations are also practicing medicine without a license by forcing physicians to use cheaper, less effective medications for patients and by restricting the ordering of certain tests for cost containment purposes even when they are clearly indicated. It might be reasonable to do so in some cases if they could really show that costs have been contained, but I have yet to see where they have. Higher and higher insurance premiums are just going to the executives and stockholders, not back to the patients.

Legal Centered Care

Of course, then, when adverse events occur, sometimes because of the restrictions under which physicians must practice, our litigious society helps to support the notion that someone must be blamed. Millions of dollars then have to be paid after a prolonged legal battle that destroys the lives and reputations of all concerned and further drives up the cost of malpractice insurance which then further assures that the costs of practicing medicine will remain higher than what is supportable by the amount of reimbursement received, unless you believe high volume with low quality is the way to go. Surely the current malpractice system is not focusing on quality of patient care as a primary goal. This is not to say that many cases are not legitimate, but many are not, and much is spent on frivolous cases that could be decided by a panel of experts rather than a lengthy, expensive court battle.

Of course, no one wants to be sued, but all who practice medicine, which, despite what you see on TV, is not an exact science, must be wary of that possibility. The torture of a medical professional having to deal with a malpractice claim, justified or not, imposes a strong sense of defensiveness resulting in lots of expensive tests being ordered that may not be required immediately.

For example, if someone is admitted to the hospital with a syncopal episode, even when it appears obvious that the problem is probably due to postural hypotension, a huge, expensive workup is ordered to cover all the possible causes of syncope. The usual tests ordered include a CT of the head followed by an MRI and MRA of the head, 72 hours of cardiac monitoring, an echocardiogram, a tilt-table test, duplex ultrasound of the carotid arteries and an EEG, not to mention a three day hospital stay. If we were not so worried about missing some rare possibility when the initial history and physical exam and laboratory studies are normal, we might just do a supine and standing blood pressure, check a CT scan, make the diagnosis of postural syncope based on that evidence, and then make the usual recommendations or medication adjustments needed to treat that diagnosis, without having to do all the other studies mentioned above; and we would be right the vast majority of the time.

However, under the current malpractice climate, if we were to do that and let the patient go home with close outpatient follow up without the MRI, etc, and if the patient is later found to have a brain tumor, we are in trouble, since we "obviously" missed the diagnosis and didn't comply with the legal "standard of care" by ordering all the above tests. Ironically, the "standard of care" for diagnosis has often been developed as a result of defensive medicine, not because of evidence, and that same standard of care is used against the physician in court.

In an ideal world, of course, we shouldn't be guided in diagnosing and treating patients by malpractice concerns or by government or insurance rules. We should be guided by what the patient requires based on medical knowledge, evidence and experience. If you're not sure of the diagnosis after initial evaluation, then by all means you need to do more testing, If the episode was clearly vasovagal or postural syncope, then you should feel comfortable not putting the patient through a lot of tests that he or she doesn't need. I think we should be thorough, but not wasteful.

Back to Patient Centered Care

The bottom line is that whatever we do in health care reform this year and in the years to come, we must return to and maintain our focus of taking care of patients, not diseases, not money, not health care organizations and executives, and not insurance companies, but patients. When we focus on anything else, the system won’t work, and patients and healthcare professionals that care about patients will remain dissatisfied. The other factors may be important in the process as a means to an end, but the primary focus should always be on patients. There will still need to be concern about the diseases, evidence and costs, but only if the goal is on better individual patient care. Medical decisions should be made by the patients, with the advice of their personal physicians, not by any other entities. If we are true to that goal, everything else will fall into its proper place.